First step in the Nursing process Assessment

Question 1

INITAL ASSESSMENT

Answer 1

Assessment performed within a specified time on admission.

EXAMPLE: Nursing admission assessmemt

Question 2

PROBLEM-FOCUSED ASSESSMENT

Answer 2

Used to determine status of a specific problem identified in an earlier assessment

EXAMPLE: Problem on urination-assess on fluid intake and urine output hourly.

Question 3

EMERGENCY ASSESSMENT

Answer 3

Rapid assessment done during any physiologic/physiologic crisis of the client to identify life threatening problems.

EXAMPLE: Assessment of clients airway, breathing status and circulation after cardiac arrest.

Question 4

TIME-LAPSED ASSESSMENT

Answer 4

Reassessment of clients functional health pattern done several months after initial assessment to compare the clients current status to baseline data previously obtained.

Question 5

WHAT WOULD THE NURSE DO DURING AN ASSESSMENT?

Answer 5

~ Observation of the patient
~ Interview patient, family and SO
~ Examination of the patient
~ Review medical record

Question 6

SUBJECTIVE DATA

Answer 6

~ Also referred to as sign/overt data.
~ Information from clients point of view
~ Information supplied by family members, significant others

EXAMPLE: Pain, Dizziness, Ringing of ears/ Tinnitus

Question 7

OBJECTIVE DATA

Answer 7

~ Also referred ti as sign/overt data
~ Those that can be detected observed or measured/tested using accepted standard or norm.

EXAMPLE: Pallor, Diaphoresis, BP = 150/100, Yellow discoloration of skin

Question 8

WHAT WOULD THE NURSE DO DURING THE INTERVIEW PROCESS OF A PATIENT?

Answer 8

~ Get information
~ Identify problems
~ Evaluate change
~ Teach or provide support or counseling

Question 9

WHAT WOULD THE NURSE DO IN THE OBSERVATION PROCESS OF A PATIENT?

Answer 9

~ Observe the patient to gather information about them by using the 5 senses and instruments.

Question 10

WHAT WOULD THE NURSE DO DURING THE EXAMINATION PROCESS OF A PATIENT?

Answer 10

~ Obtain systematic data to detect health problems using unit of measurements, physical examination techniques (IPPA) and Interpretation of laboratory results

Question 11

DURING THE EXAMINATION PROCESS OF THE PATIENT WHAT ORDER SHOULD THE NURSE DO TO KEEP IT SYSTEMATICALLY CORRECT?

Answer 11

~ Cephalocaudal approach - Head-to-toe assessment
~ Body system approach - Examine the whole body system
~ Review of system approach - Examine only particular area affected

Question 12

WHAT ARE ARE CUES THE NURSE SHOULD LOOK FOR?

Answer 12

Subjective or objective data observed by the nurse; It is what the client says or what the nurse can see, hear, feel, smell or measure.

Question 13

WHAT ARE EXAMPLES OF INFERENCES THE NURSE SHOULD MAKE BASED ON THE CUES?

Answer 13

~ Red Swollen Wound = Infected Wound

~ Dry Skin = Dehydrated